Melanoma and the wrong site

Dr. GoldbergDr. Cancer is a well-respected dermatologic surgeon who receives referrals from many physicians. He is well known for his expertise in skin cancer removal. He holds an academic title and lectures nationally on the treatment of melanoma. All patients referred to him are required to bring biopsy reports. Some even come with photographs of the biopsied area. Most patients have a pretty good idea of where the biopsy was taken. Two years ago, Dr. Cancer saw a patient with a biopsy proven melanoma in situ of the right cheek. The patient, during initial consultation, also brought a photo of the involved area. Because the patient was so anxious about her upcoming surgery, Dr. Cancer suggested she take an anti-anxiety medication prior to surgery. Consent forms were signed during the consultation appointment.

On the day of surgery, Dr. Cancer’s patient took a double dosage of her anti-anxiety medication. She was sleepy and confused when she entered Dr. Cancer’s office. Unfortunately, it was not a good day in Dr. Cancer’s office. The staff provided local anesthesia to the wrong site. Dr. Cancer followed by removing a significant segment of the wrong area of skin and did not remove the melanoma. As the staff began to teach the patient appropriate wound care, the patient’s family noticed that surgery was performed on the wrong site. Needless to say, they were appalled.  They never returned to the office and filed both a medical malpractice lawsuit and a claim with Dr. Cancer’s state board of medical examiner. Now what?

Unfortunately, wrong site surgeries do happen. Over two decades ago a world-renowned New York neurosurgeon lost his medical license for operating on the wrong side of a patient’s brain. A Rhode Island hospital was penalized a decade ago for allowing five wrong-site surgeries to be performed over the previous three years. The hospital was forced to pay a $150,000 fine, participate in mandatory safety training for all personnel involved in performing elective surgeries; and, a proctor was assigned to monitor surgical teams to ensure safety protocols would be followed. But even more was required:  The Health Department mandated that the hospital install video and audio monitoring equipment in each operating room. There would now be a record of not only the banter that goes on during surgery, but also the music. It was felt that such radical measures would get to the root cause of the problem. Patients of course needed to give consent to be videotaped.

Wrong site surgery is considered a "never event." Medicare does not pay for a repeat surgery if the first one is on the wrong body part and a number of private insurance companies have stopped paying as well.

Wrong site surgery is preventable

One way to decrease the likelihood of such embarrassing (and potentially mutilating) events from happening is to get the patient involved. Explain to the patient before surgery that operating on the proper side is the first priority of surgery. The patient can be given a marker to label the spot. He or she should initial on the consent form as to the appropriate location. This should be double checked on the day the patient arrives for surgery. Most patients will appreciate the extra attention paid to this process.

Other steps should be taken, including a time out before cutting to ensure that more than one team member has identified the proper spot and has verified the proper side with a pre-op biopsy report, pre-biopsy photos and consent form.

There are times when patients are unclear as to the exact location of a biopsy. There are times when biopsies are mislabeled. There are many times when there are no photographs. However, the hallmark of medicine is to do no harm. It is a clear-cut breach in the standard of care to operate on one site when the cancerous lesion was in fact present on a different site. Once the malpractice case is filed based on the above fact pattern, most attorneys would advise Dr. Cancer to settle the case out of court. Similarly, Dr. Cancer needs to try to settle with the State Board of Medical Examiners. There may often be some confusion as to where a biopsy was taken. Proper site delineation is required.